Pancreaticoduodenal malignancies commonly present with simultaneous biliary and duodenal obstruction, resulting in jaundice, vomiting, nutritional decline, and marked deterioration in quality of life. Most affected patients are unsuitable for surgery. Conventional management often requires multiple staged interventions, including ERCP, duodenal stenting, percutaneous biliary drainage, and surgical gastrojejunostomy.

Endoscopic ultrasound (EUS)-guided gastrojejunostomy (GJ) and biliary drainage (BD) have emerged as effective palliative strategies. Performing both in a single session offers an efficient method to relieve double obstruction while minimising procedural burden.

This study evaluates the technical success, clinical success, and safety of single-session EUS-guided double bypass for palliation of malignant biliary and duodenal obstruction. We hypothesised that this approach would achieve high technical and clinical success, improve symptoms rapidly, reduce the need for multiple procedures and prolonged hospitalisation, and maintain an acceptable safety profile.

This single-centre, retrospective observational cohort study was conducted at University Hospital Southampton, United Kingdom, from September 2023 to September 2025. Primary outcomes were technical success (successful completion of both EUS-guided bypass procedures) and clinical success (reduction in bilirubin and improvement in obstructive symptoms). Secondary outcomes included procedural safety and early recovery metrics. Statistical analysis was performed using Stata.

Eighteen patients were screened, and sixteen met inclusion criteria. The cohort comprised 6 males and 10 females, with a median age of 63.6 years. Underlying malignancies included pancreatic adenocarcinoma and duodenal cancers: head of pancreas (40%), duodenum (40%), and ampulla (20%).

All 16 patients underwent single-session EUS-GJ and EUS-BD. Biliary drainage techniques included EUS-GJ + choledochoduodenostomy (CDD; n=4) and EUS-GJ + hepatogastrostomy (HGS; n=12).

• Technical success: 16/16 (100%)
• Clinical success: 16/16 (100%)
• Median time to oral intake: 3 days
• Median length of stay: 3.6 days

Adverse events occurred in 2 patients (12.5%): one bile-leak biliary peritonitis and one probable ischaemic injury following EUS-HGS. The 30-day mortality was 30%, predominantly related to underlying disease progression rather than procedural complications.

Single-session EUS-guided double bypass appears to be a safe, feasible, and highly effective palliative option for patients with malignant biliary and duodenal obstruction. The high technical and clinical success rates, early return to oral intake, and acceptable adverse-event profile suggest that this approach may reduce the need for multiple invasive procedures and streamline palliative care pathways.